RALEIGH, N.C. (AP) — State health officials report the death toll from the seasonal flu outbreak has risen to 21, leading to a renewed call for residents across North Carolina to get vaccinated.

The N.C. Department of Health and Human Services said Thursday that of the 21 deaths, 19 have been young and middle-aged adults, most of whom had underlying medical conditions. Only two deaths have been reported in persons over 65.

For the comparable period last year, the state reported 35 flu-related deaths. In all, 59 people died from the flu in the 2012-2013 flu season in North Carolina. Of those, six were between the ages of 25 and 49.

During the 2009-2010 flu season, the agency reported 107 deaths. That was the year of the H1N1 pandemic.

Health officials said flu activity has been widespread in North Carolina since mid-December. Flu season typically peaks during January and February.

State Health Director Robin Gary Cummings is encouraging flu vaccination as the best protection, especially for women who are pregnant, people who are obese and people with medical conditions like heart disease or lung disease that place them at higher risk.

“Those at higher risk of complications from flu should see a doctor right away if they suspect they might have influenza,” Cummings said. “Early treatment with antiviral medicine is an important second line of defense for those who become ill.”